Prescott Animal Hospital (PAH Holdings PC) Annual Report (Arizona Corporation Commission) (2017)

STATE OF ARIZONA AZ iii Commission
Copy CORPORATION commission _ lI NINN

CORPORATION ANNUAL REPORT 05819071

& CERTIFICATE OF DISCLOSURE ey

DUE ON OR BEFORE 3/29/2017 FILINGFEE $45.00

PLEASE READ ALL INSTRUCTIONS. The following information is required by A.R.S. §§10-1622 & 10-11622 for all corporations
organized pursuant to Arizona Revised Statutes, Title 10. The Commission’s authority to prescribe this form is A.R.S. §§ 10-
121(A) & 10-3121(A). YOUR REPORT MUST BE SUBMITTED ON THIS ORIGINAL FORM. Make changes or corrections where
necessary. Information for the report should reflect the current status of the corporation.

08713675 RECEIVED
4... PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C.
1318 IRON SPRINGS RD MAR 0 9 2017
ARIZONA CORP, COMMISSION
CORPORATIONS DIVISION

PRESCOTT, AZ 86305

Business Phone?|0~ Yuc- eww

State of Domicile: ARIZONA

(Business phone is optional.)
ation:

Statutory Agent: MICHAEL L RUBIN Statutory Agent's Street or Physical Address, If Different.
Mailing Address: 230 ANDERSON RD
City, State, Zip: PRESCOTT, AZ 85303

If appointing a new statutory agent, the new agent MUST consent to that
appointment by signing below. Note that the agent address must be in Arizona.

1, (individual) or We, (corporation or limited liability company) having been designated the new Statutory Agent,
do hereby consent to this appointment until my removal or resignation pursuant to law.

H ‘Signature of new Statutory Agent |

Printed Name of new Statutory Agent
3. Secondary Address:
(Foreign Corporations are REQUIRED
to complete this section).

4. Check the one category below which best describes the CHARACTER OF BUSINESS of your corporation.
NON-PROF}

08713675 PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C. Page2
Business trusts must indicate the number of transferable certificates held by trustees evidencing their beneficial interest in the trust
estate. PLEASE PRINT OR TYPE CLEARLY.

5a. Please examine the corporation's original Articles of Incorporation for the amount of shares authorized.
Number of Shares/Certificates Authorized Class Series Within Class (if any)
100000.00 COMMON

5b. Review all corporation amendments to determine if the original number of shares has changed. Examine the corporation's
minutes for the number of shares issued.

Number of Shares/Certificates Issued Class
2000.00 COMMON

Series Within Class (if any)

6. SHAREHOLDERS: ((For-profit Corporations and Business Trusts are REQUIRED to complete this section.)
List shareholders holding more than 20% of any class of shares issued by the corporation, or having more than a 20% beneficial

interest in the corporation.
Name: DR BRYAN K NOLTE
NONE oO

Name: DR KENNETH C SKINNER

Name: DR CAMERON S DOW

Name:

7. OFFICERS PLEASE TYPE OR PRINT CLEARLY. YOU MUST LIST AT LEAST ONE.

Name: DR KENNETH C SKINNER
Title: PRESIDENT/CEO
Address: 783 PEPPERMINT WAY

PRESCOTT, AZ 86305
Date taking office: 01/01/2013
ame: DR BRYAN K NOLTE

Title: VICE-PRESIDENT
Address: 7685 N DEERFIELD DR

PRESCOTT, AZ 86305
Date taking office: 01/01/2003

Name: DR CAMERON S DOW
Title: VICE-PRESIDENT
Address: 793 GRAPEVINE LANE

PRESCOTT, AZ 86305
Date taking office: 05/04/2015

Date taking office:

8. DIRECTORS "CKIRE AS AXRE OR PRINT CLEARLY. YOU MUST LIST AT LEAST ONE.

Name: DR S DOW
Address: 793 GRAPEVINE LN

PRESCOTT, AZ 85601
Date taking office: 05/04/2015
Name: DR KENNETH C SKINNER
Address: 783 PEPPERMINT WAY

PRESCOTT, AZ 86305
Date taking office: 01/01/1997

AR:0046
Rev. 08/2016

Name: _DR BRYAN K NOLTE
Address: 7685 N DEERFIELD DR

PRESCOTT, AZ 86305
Date taking office: 01/01/2000

Name:
Address:
Date taking office:
Arizona Corporation Commission
Corporations Division

Please Enter Corporation Name: PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C. File number 08713675 Page 3

9. FINANCIAL DISCLOSURE (A.R.S. §10-11622(A)(9))
Nonprofits — financial disclosure is no longer required. Cooperative marketing associations — must submit a financial statement. All other types
of corporations are not required to file a financial statement.

ONLY NONPROFIT CORPORATIONS MUST ANSWER THIS QUESTION:
9A. MEMBERS (A.R.S. §10-11622(A)(6)) This corporation DOES LJ DOES NOTE have members.

2: CERTIFICATE OF DISCLOSURE (A.R.S. §§ 10-202(D), 10-3202(D), 10-1622(A)(8) & 10-11622(A}(7))
Has any person who is currently an officer, director, trustee, incorporator, or who, in a For-profit corporation, controls or holds more than
10% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation
been:

1. Convicted of a felony involving a transaction in securities, consumer fraud or antitrust in any state or federal jurisdiction within the five year
period immediately preceding the execution of this certificate?
2. Convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by false pretenses or restraint of trade or
monopoly in any state or federal jurisdiction within the five year period immediately preceding execution of this certificate?
3. Subject to an injunction, judgment, decree or permanent order of any state or federal court entered within the five year period immediately
preceding execution of this certificate where such injunction, judgment, decree or permanent order involved the violation of:
(a) fraud or registration provisions of the securities laws of that jurisdiction, or
(b) the consumer fraud laws of that jurisdiction, or
(c) the antitrust or restraint of trade laws of that jurisdiction?

One box must be marked: YESO NO

If"YES" to A, the following information must be submitted as an attachment to this report for each person subject to one or mor
actions stated in Items 1 through 3 above.
"4. Full birth name. 5. Date and location of birth.
2. Full present name and prior names used. 6. The nature and description of each conviction or judicial
3. Present home address. action; the date and location; the court and public agency
4. All prior addresses for immediately preceding 5 year involved; and the file or cause number of the case.
period.

B. Has any person who is currently an officer, director, trustee, incorporator, or who, in a For-profit corporation, controls or holds over 20% of
the issued and outstanding common shares, or 20% of any other proprietary, beneficial or membership interest in the corporation, served
in any such capacity or held a 20% interest in any other corporation on the bankruptcy or receivership of that other corporation?

One box must be marked: YES(] NO
If “YES” to B, the following information must be submitted as an attachment to this report for each corporation subject to th
statement above.
(a) Name and address of each corporation and the persons involved.
(b) State(s) in which it: (i) was incorporated and (ii) transacted business.
(c) Dates of corporate operation.

11. STATEMENT OF BANKRUPTCY OR RECEIVERSHIP (A.R.S. §§ 10-1623 & 10-11623)

A. Has the corporation filed a petition for bankruptcy or appointed a receiver? One box must be marked: YESQ NO
If “Yes” to A, the following information must be submitted as an attachment to this report:

1. All officers, directors, trustees and major stockholders of the corporation within one year of filing the petition for bankruptcy or the
appointment of a receiver. If a major stockholder is a corporation, the statement shall list the current president, chairman of the
board of directors and major stockholders of such corporate stockholder. “Major stockholder” means a shareholder possessing or
controlling twenty per cent of the issued and outstanding shares or twenty per cent of any proprietary, beneficial or membership
interest in the corporation.

2. Whether any such person has been an officer, director, trustee or major stockholder of any other corporation within one year of the
bankruptcy or receivership of the other corporation. If so, for each such corporation give:

(a) Name and address of each corporation;
(b) States in which it: (i) was incorporated and _ (ji) transacted business.
(c) Dates of operation.
12. SIGNATURES: [ Annual Reports must be sig ined and dated by at least one duly authorized officer or they will be rejected.
I declare, under penalty of perjury, that all corporate income tax returns required by Title 43 of the Arizona Revised Statutes have been

filed with the Arizona Depa it of Revenue. | further declare under penalty of perjury that | (we) have examined this report and the
ments, and to the best of my (our) knowledge and belief they are true, correct and complete.

; pateZ/-/7 Name Lanes pate<-/-/7
Signature. Signature A

Title. tite L7es Le,

(Signator(s) must be duly authorized corporate officer(s) listed in section 7 of this report.)

AR:0046 Arizona Corporation Commission
Rev. 08/2016 Corporations Division